Provider Demographics
NPI:1578585527
Name:DETJEN, PAULA JOY (LMFT)
Entity Type:Individual
Prefix:
First Name:PAULA
Middle Name:JOY
Last Name:DETJEN
Suffix:
Gender:F
Credentials:LMFT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1000 SUPERIOR DR
Mailing Address - Street 2:
Mailing Address - City:NORTHFIELD
Mailing Address - State:MN
Mailing Address - Zip Code:55057-4873
Mailing Address - Country:US
Mailing Address - Phone:507-581-0430
Mailing Address - Fax:
Practice Address - Street 1:706 DIVISION ST S
Practice Address - Street 2:
Practice Address - City:NORTHFIELD
Practice Address - State:MN
Practice Address - Zip Code:55057-2427
Practice Address - Country:US
Practice Address - Phone:507-581-0430
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-25
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN1399106H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106H00000XBehavioral Health & Social Service ProvidersMarriage & Family Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN11-3791736-001OtherAMERICA'S PPO